SITUATION
Nancy Foster is a senior in college and lives at home with her parents. She works part time as a server in a restaurant. Nancy is outgoing and has plans to further her education by attending graduate school. Diagnosed with diabetes at age 15, keeping her diabetes under control is a constant concern. She recently began using an insulin pump. She has presented today for her regular
six-month examination and prophylaxis.
LEARNING GOALS
Following integration of core scientific concepts and application of the dental hygiene process of care relating to this patient, you will be able to
1. Assess patient characteristics.
A. Identify the classifications of diabetes using current medical terminology.
B. Determine the etiology of diabetes based on patient health history information.
C. Classify fluorosis.
D. Recognize diabetes effects on the oral cavity. E. Relate pathophysiology of diabetes with clin-
ical symptoms.
2. Obtain and interpret radiographs.
A. Identify common radiographic artifacts. B. Identify the cause of errors that diminish
the quality of radiographs.
C. Apply the appropriate corrective action to radiographic error.
D. Identify normal radiographic landmarks. E. Use radiographs to classify carious lesions
according to G. V. Black’s method of classification.
F. Interpret deviations from normal radio- graphic anatomy.
3. Plan and manage dental hygiene care.
A. Recognize and manage a medical emer- gency during dental hygiene treatment.
4. Perform periodontal procedures.
A. Classify the patient’s periodontal condition using the American Academy of Periodon- tology classification system.
B. Identify the causes of change in gingival tissues.
C. Assess outcomes of nonsurgical periodon- tal therapy.
D. Describe the wound-healing process. E. Appropriately recommend recare appoint-
ment time intervals.
5. Use preventive agents.
A. Select appropriate teeth for pit and fissure sealant application.
B. Select preventive agents based on patient needs.
6. Provide supportive treatment services.
A. Recognize conditions that decrease the effec- tiveness of tooth whitening.
7. Demonstrate professional responsibility.
A. Use health history follow-up questions to open communication with the patient for the purpose of avoiding the occurrence of a medical emergency during treatment.
Clinically visible carious lesion Clinically missing tooth Furcation
“Through and through” furcation Probe 1: Initial probing depth Probe 2: Probing depth 6 weeks after
periodontal therapy VITAL SIGNS Age Gender Height Weight Blood Pressure Pulse Rate Respiration
1. Under care of physician
Yes No
5. Smokes or uses tobacco products
Yes No
6. Is pregnant
Yes No N/A
2. Hospitalized within the last 5 years
Yes No
3. Has or had the following conditions
4. Current medications Condition: Reason: X X X X diabetes mellitus
glycated hemoglobin test every 3 months
insulin regular (Humulin®R)—insulin neutral protamine hagedorn (NPH) (Humulin®N)—insulin 21 years female 5′ 3″ 106 lbs. 90/60 mm Hg 96 bpm 14 rpm
MEDICALLY COMPROMISED PATIENT—Nancy Foster PATIENT HISTORY SYNOPSIS
F P R L L F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 324 213 Probe 2 Probe 1 Probe 1 Probe 2 Probe 1 Probe 2 Probe 2 Probe 1 313 323 334 313 313 323 312 323 212 212 212 212 111 211 111 111 111 111 111 111 111 112 323 323 313 313 112 212 212 323 323 313 323 212 212 111 212 111 111 111 111 111 212 111 434 323 433 323 323 212 534 413 211 322 111 212 111 212 111 212 111 212 111 212 212 323 212 325 312 523 323 313 524 313 322 212 212 212 212 111 212 111 212 111 223 111 323 212 212 323 323 212 323 212
ADULT CLINICAL EXAMINATION
MEDICAL HISTORY
Has experienced a recent weight loss of seven lbs.
DENTAL HISTORY
Receives regular dental hygiene care at six-month intervals; orthodontic treatment in her early teens. States that she grew up in a region with heavily fluoridated water so she has chosen not to use a fluoride toothpaste.
SOCIAL HISTORY
A busy full-time college student with a part-time job, patient admits to less than ideal eating habits. Has a habit of biting her fingernails.
CHIEF COMPLAINT
Recently noticed that her gums look different and that they are sore and bleed easily. Interested in tooth whitening.
CURRENT ORAL HYGIENE STATUS
Slight, localized calculus in the mandibular anterior region. Slight, generalized plaque biofilm.
SUPPLEMENTAL ORAL EXAMINATION FINDINGS
Moderate, generalized bleeding upon probing. Moderate xerostomia.
Chapter 15
Case M
181
R L R L
6-week reevaluation appointment
R L
Right side
R L
Chapter 15 Case M 183
CASE STUDY QUESTIONS
ASSESSING PATIENT CHARACTERISTICS
Basic Level Questions
1. Based on the current American Diabetes Association classification system, this patient has which of the following?
A. Type 1 diabetes B. Type 2 diabetes C. Gestational diabetes D. Drug-induced diabetes
2. Which of the following was the most likely etiology in the development of this patient’s diabetes?
A. Insulin resistance
B. Inadequate insulin secretion
C. Autoimmune destruction of beta cells D. Poor weight management
E. Sucrose consumption
3. Based on the Tooth Surface Index of Fluorosis (TSIF) classification system, what is this patient’s numerical score?
A. 0 B. 1 C. 2 D. 3 E. 4
Competency Level Questions
4. What is the most likely cause of this patient’s xerostomia? A. Periodontal disease
B. Medication use C. Renal function D. Frequent meals
E. Oral hygiene
5. Which of the following would NOT be related to poor glycemic control? A. Dental caries
B. Weight loss C. Increased pulse rate D. Congenitally missing teeth
E. Low blood pressure
6. This patient’s medical condition has the potential to increase her risk for each of the following oral manifestations EXCEPT one. Which one is the EXCEPTION?
A. Gingivitis B. Periodontitis
C. Burning mouth syndrome D. Oral mucosal diseases
OBTAINING AND INTERPRETING RADIOGRAPHS
Basic Level Questions
7. Which of the following is the most likely interpretation of the round radiolucency at the incisal edge of the mandibular right central incisor observed in the mandibular right lateral canine periapical radiograph (arrow)?
A. Film identification dot B. Composite restoration C. Attrition
D. Calculus deposit E. Caries
8. Which of the following has rendered the maxillary right premolar periapical radio- graph undiagnostic?
A. Interproximal spaces overlapped B. Root apices not visible
C. Conecutting present D. Herringbone effect
E. Image receptor holder imaged
Competency Level Questions
9. What corrective action is required when retaking the undiagnostic maxillary right premolar periapical radiograph?
A. Decrease the vertical angulation.
B. Shift the horizontal angulation to the mesial.
C. Ensure that the patient bites down on the image receptor holder. D. Reverse the image receptor when placing into the oral cavity.
E. Center the image receptor within the x-ray beam.
10. Which of the following is the most likely interpretation of the radiolucent vertical line between the maxillary central incisors (arrow)?
A. Nasal septum B. Nutrient canal C. Vertical bone loss D. Palatal fracture
E. Midpalatine suture
11. The radiographs reveal which G. V. Black’s classification of caries on the maxillary left first molar? A. II B. III C. IV D. V E. VI
12. Which of the following is the most likely interpretation of the radiopaque anomaly near the roots of the mandibular left first molar (arrow)?
A. Microdont B. Mesiodens C. Secondary dentin D. Enamel pearl
E. Pulp stone
13. Which of the following teeth presents with root dilaceration? A. Maxillary right second premolar
B. Maxillary left first molar C. Mandibular left canine
D. Mandibular right central incisor E. Mandibular right second molar
Chapter 15 Case M 185
PLANNING AND MANAGING DENTAL HYGIENE CARE
Basic Level Questions
14. Which of the following would be considered the most likely medical emergency that may occur with this patient during treatment?
A. Hyperglycemia B. Hypoglycemia C. Diabetic coma D. Ketoacidosis
15. Each of the following indicates that this patient is experiencing a medical emergency EXCEPT one. Which one is the EXCEPTION?
A. Excessive perspiration B. Palpitations
C. Slight paresthesia D. Increased anxiety
E. Argumentative mood
Competency Level Question
16. Which of the following will assist in managing a possible emergency medical situation regarding this patient?
A. Premedicate with oral antibiotics.
B. Place ammonia capsule on the bracket table for ready use.
C. Request that the patient disconnect the insulin pump during treatment. D. Use a semisupine chair position.
E. Have a glucose tablet or source of oral sugar (e.g., orange juice) available.
PERFORMING PERIODONTAL PROCEDURES
Basic Level Question
17. Based on the American Academy of Periodontology classification system, what is this patient’s periodontal classification?
A. Gingivitis associated with dental plaque only B. Nonplaque-induced gingival disease C. Gingival disease modified by medications D. Gingival disease modified by systemic factors
E. Gingival manifestations of systemic conditions
Competency Level Questions
18. On a histologic level, each of the following is responsible for the color change of the gingiva observed at the initial appointment in the facial region of the maxillary right central incisor EXCEPT one. Which one is the EXCEPTION?
A. Blood flow to this area has increased.
B. Many dead and dying phagocytes are present.
C. Osteoclast activity is being stimulated by prostaglandins. D. Leukocytes are invading the bacteria present at this site.
E. Plasma proteins are leaking from the blood vessels in the tissue.
19. What is the reason for the change in appearance of the facial gingiva in the region of the mandibular right central incisor at the six-week reevaluation appointment?
A. Weight gain of lost pounds B. Cessation of nail-biting habit C. Change in method of insulin delivery D. Initiation of use of whitening products
20. Order these steps responsible for the change in appearance noted in the gingival tissue in the facial region of the mandibular right central incisor at the six-week evaluation appointment. Match each letter with its proper sequence number.
Begin with the first step.
1. ___ A. Wound contraction by the action of myofibroblasts 2. ___ B. Synthesis of extracellular matrix (ECM) proteins and
collagen deposition
3. ___ C. Inflammatory response
4. ___ D. Tissue maturation and remodeling
5. ___ E. Formation of new blood vessels (angiogenesis) and granulation tissue
21. Which of the following maintenance appointment intervals would benefit this patient? A. 1 month
B. 3 months C. 6 months D. 9 months E. 12 months
USING PREVENTIVE AGENTS
Basic Level Question
22. Which of the following should be indicated for placement of a sealant? A. Maxillary right second molar
B. Maxillary right first molar C. Maxillary left first molar D. Mandibular left first molar
E. Mandibular right first molar
Competency Level Question
23. Which of the following would benefit this patient the most? A. End-tuft brush
B. Tooth whitening product C. Power flosser
D. Self-applied fluoride E. Disclosing tablets
PROVIDING SUPPORTIVE TREATMENT SERVICES
Competency Level Question
24. Which of the following can be expected to minimize tooth whitening results for this patient? A. Gingival inflammation B. Nail-biting habit C. Fluorosis D. Diabetes E. Sealants
Chapter 15 Case M 187
DEMONSTRATING PROFESSIONAL RESPONSIBILITY
Basic Level Question
25. Each of the following is a recommended health history interview question to determine the safe treatment of this patient today EXCEPT one. Which one is the EXCEPTION?
A. “Did you take your usual dose of insulin today?” B. “How often do you have insulin reactions?” C. “What was your blood glucose level at the last test?” D. “Have you eaten your normal meals and snacks today?”
E. “How much do you weigh?”
SETTING PATIENT GOALS
ESTABLISHING A DENTAL HYGIENE CARE PLAN
To assist this patient in meeting her needs, develop a dental hygiene care plan that estab- lishes a framework within which to help her identify goals for obtaining oral health. In addi- tion to the clinical assessment, a well-prepared dental hygiene care plan should take into account the patient’s age, gender, lifestyle, culture, attitudes, health beliefs, and knowledge level. To help link this patient’s needs for overall well-being with her oral conditions, and to provide motivation for achieving better health, the following is a partial list of possible deficits based on the Human Needs Conceptual Model to Dental Hygiene Practice (see Chapter 1). Use this partial list of unmet needs or deficits as a guide in preparing a dental hygiene care plan for this patient. One set of goals and dental hygiene actions/interventions has been completed as an example.
Deficit identified in protection from health risks Due to: inadequate nutrition
Evidenced by: self-report
Goals: ______________________________________________________________ Dental hygiene actions/interventions: ____________________________________ Deficit identified in wholesome facial image
Due to: color of teeth
Evidenced by: request for whitening products